Physiotherapy and exercise

Keeping active can improve your posture and range of spinal movement, along with preventing your spine from becoming stiff and painful.

As well as keeping active, physiotherapy is a key part of treating AS. A physiotherapist (a healthcare professional trained in using physical methods of treatment) can advise about the most effective exercises and draw up an exercise programme that suits you.

Types of physiotherapy recommended for AS include:

a group exercise programme – where you exercise with others

an individual exercise programme – you are given exercises to do by yourself

massage –your muscles and other soft tissues are manipulated to relieve pain and improve movement (the bones of the spine should never be manipulated as this can cause injury in people with AS)

hydrotherapy –exercise in water (usually a warm, shallow swimming pool or a special hydrotherapy bath); the buoyancy of the water helps make movement easier by supporting you, and the warmth can relax your muscles

Some people prefer to swim or play sport to keep flexible. This is usually fine, although some daily stretching and exercise is also important.

If you're ever in doubt, speak to your physiotherapist or rheumatologist before taking up a new form of sport or exercise.

Painkillers

You may need painkillers to manage your condition while you are being referred to a rheumatologist. The rheumatologist may continue prescribing painkillers, although not everyone needs them all the time.

When prescribing NSAIDs, your GP or rheumatologist will try to find the one that suits you, and the lowest possible dose that relieves your symptoms. Your dose will be monitored and reviewed as necessary.

Paracetamol

If NSAIDs are unsuitable for you, an alternative painkiller, such as paracetamol, may be recommended.

Paracetamol rarely causes side effects and can be used in women who are pregnant or breastfeeding. However, paracetamol may not be suitable for people with liver problems or those dependent on alcohol.

Codeine

If necessary, as well as paracetamol, you may also be prescribed a stronger type of painkiller called codeine.

Codeine can cause side effects including feeling sick, vomiting, constipation and drowsiness.

Anti-TNF medication

If your symptoms cannot be controlled using painkillers or exercising and stretching, anti-TNF (tumour necrosis factor) medication may be recommended. TNF is a chemical produced by cells when tissue is inflamed.

Anti-TNF medications are given by injection and work by preventing the effects of TNF, as well as reducing inflammation in your joints caused by ankylosing spondylitis.

These are relatively new treatments for AS, and their long-term effects are unknown.

However, they have been used for longer in people with rheumatoid arthritis, and this is providing clearer information about their long-term safety.

If your rheumatologist recommends using anti-TNF medication, the decision about whether they are right for you must be discussed carefully and your progress will be closely monitored. This is because anti-TNF medication can interfere with the immune system (the body’s natural defence system), increasing your risk of developing potentially serious infections.

NICE guidelines

The National Institute for Health and Care Excellence (NICE) has produced guidance about the use of anti-TNF medication for AS. NICE states that adalimumab, etanercept and golimumab may only be used if:

treatment with two or more NSAIDs for four weeks at the highest possible dose has not controlled your symptoms

After 12 weeks of treatment with anti-TNF medication, your pain score and BASDAI will be tested again to see whether they have improved enough to make continuing treatment worthwhile. If they have, treatment will continue and you will be tested every 12 weeks.

If there is not enough improvement after 12 weeks, you will be tested again at a later date or the treatment will be stopped.

Corticosteroids

Corticosteroids have a powerful anti-inflammatory effect and can be taken as tablets or injections by people with AS.

If a particular joint is inflamed, corticosteroids can be injected directly into the joint. After the injection, you will need to rest the joint for up to 48 hours.

It is usually considered wise to have a corticosteroid injection up to three times in one year, with at least three months between injections in the same joint. This is because corticosteroids injections can cause a number of side effects, such as:

infection in response to the injection

the skin around the injection may change colour (depigmentation)

the surrounding tissue may waste away

a tendon (cord of tissue that connects muscles to bones) near the joint may rupture (burst)

Corticosteroids may also calm down painful swollen joints when taken as tablets.

Disease-modifying anti-rheumatic drugs (DMARDs)

Disease-modifying anti-rheumatic drugs (DMARDs) are an alternative type of medication often used to treat other types of arthritis.

DMARDs may be prescribed for AS, although they are only beneficial in treating pain and inflammation in joints in areas of the body other than the spine.

Surgery

Most people with AS will not need surgery.

However, in cases where a joint has become severely damaged, joint replacement surgery may be recommended to improve pain and movement in the affect joint. For example, if the hip joints are affected, a hip replacement may be carried out.

In rare cases, corrective surgery may be needed if the spine becomes badly bent.

Follow-up

As the symptoms of AS develop slowly and tend to come and go, you will need to see your rheumatologist or GP for regular check-ups.

They will make sure your treatment is working properly and may carry out physical assessments to assess how your condition is progressing. This may involve further sets of the same blood tests or X-rays you had at the time of your diagnosis.